Fill Out Form Medical History New

429 N. Ferncreek Avenue, Orlando, FL 32803

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Medical History Fields marked with * are required

First Name *

Last Name *

Health History Fields marked with * are required

Have you been hospitalized in the last two years? * Yes No

For What?

Have you ever been hospitalized? * Yes No

For What?

Are you currently being treated by a physician? * Yes No

If Yes:

Have you ever had a serious head or neck injury? * Yes No

If Yes:

Are you taking any medications, pills, or drugs? * Yes No

If Yes:

Do you take, or have you taken, Phen-Fen or Redux? * Yes No

If Yes:

Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates? * Yes No

If Yes:

Are you on a special diet? * Yes No

If Yes:

Do you use tobacco? * Yes No

Do you use controlled substances? * Yes No

If Yes:

Women: Are you pregnant / Trying to get pregnant? * Yes No

Nursing? * Yes No

Taking oral contraceptives? * Yes No

Are you allergic to any of the following? Fields marked with * are required

Aspirin * Yes No

Penicillin * Yes No

Codeine * Yes No

Acrylic * Yes No

Metal * Yes No

Latex * Yes No

Sulfa Drugs * Yes No

Local Anesthetics * Yes No

Other? * Yes No

If Yes:

Sleep Medicine Questionnaire Fields marked with * are required

Have you been diagnosed with sleep apnea? Yes No

Do you have a CPAP? Yes No

If so, how many nights per week do you wear your CPAP?

On nights when you wear your CPAP, how many hours do you typically wear it?

Do you snore or have you ever been told that you snore, stop breathing, or gasp for air when you sleep? Yes No

After a typical night's sleep, do you feel refreshed? Yes No

Have you been diagnosed with atrial fibrillation (AFib)? Yes No

If you have high blood pressure, is it well-controlled? Yes No

If no, how many blood pressure medications are you currently taking?

Do you have, or have you had, any of the following? Fields marked with * are required

AIDS/HIV Positive

Alzheimer's Disease

Anaphylaxis

Anemia

Angina

Arthritis/Gout

Artificial Heart Valve

Artificial Joint

Asthma

Blood Disease

Blood Transfusion

Breathing Problems

Bruise Easily

Cancer

Chemotherapy

Chest Pains

Cold Sores / Fever Blisters

Congenital Heart Disorder

Convulsions

Yellow Jaundice

Cortisone Medicine

Diabetes

Drug Addiction

Easily Winded

Emphysema

Epilepsy or Seizures

Excessive Bleeding

Excessive Thirst

Fainting Spells / Dizziness

Frequent Cough

Frequent Diarrhea

Frequent Headaches

Genital Herpes

Glaucoma

HayFever

Heart Attack / Failure

Heart Murmur

Heart Pacemaker

Heart Trouble / Disease

Sleep Apnea

Hemophilia

Hepatitis A

Hepatitis B or C

Herpes

High Blood Pressure

High Cholesterol

Hives or Rash

Hypoglycemia

Irregular Heartbeat

Kidney Problems

Leukemia

Liver Disease

Low Blood Pressure

Lung Disease

Mitral Valve Prolapse

Osteoporosis

Pain In Jaw Joints

Parathyroid Disease

Psychiatric Care

Snoring

Radiation Treatments

Recent Weight Loss

Renal Dialysis

Rheumatic Fever

Rheumatism

Scarlet Fever

Shingles

Sickle Cell Disease

Sinus Trouble

Spina Bifida

Stomach / Intestinal Disease

Stroke

Swelling Of Limbs

Thyroid Disease

Tonsillitis

Tuberculosis

Tumors or Growths

Ulcers

Venereal Disease

Have you ever had any serious illnes not listed? * Yes No

If Yes:

Comments

Did you know that we offer cosmetic and therpuetic Botox and Dermal Filler? If you are interested, please check the boxes below. Fields marked with * are required

Forehead Lines

Lip appearance and texture

Frown lines

Thin Lips

Crow's feet lines

Double chin

Flattened cheeks / sunken cheeks

Thinning or inadequate lashes

Lines and wrinkles around the nose and mouth

Skin appearance and texture

Signature Fields marked with * are required

Date: 4/27/2024

HOURS OF OPERATION

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